Patrick R. Coonan

Article / Updated 09-21-2020

The people who make up the NCLEX-RN exam like everything to be neatly organized, so they take a list of topics to be covered on the test and break each topic down into categories and subcategories. The test consists of four categories of topics with subcategories: safe and effective care, health promotion and maintenance, psychosocial integrity, and physiological integrity. Each of these categories and subcategories is classified as a “client need.” The idea is that all your patients’ needs fit into one of the categories listed in the following sections, whether it’s a need for pain medication or a need for a chocolate milkshake. Understanding the categories gives you a good idea of how this test is constructed and what areas questions come from. You definitely will see questions from each of these general areas on the exam. As if categories and subcategories weren’t enough, the following processes are integrated throughout: Caring Communication Documentation Teaching The client needs categories exist to cover and test you on just about any nursing problem, action, or intervention from the cradle to the grave. The following sections break down the categories, with the most common topics related to each listed below the subcategory titles. Not sure what to focus on? On the content side, the four categories and their subcategories comprise certain percentages of questions addressing each topic on the exam. They’re all pretty close percentage-wise, but a few sections are a bit more heavily weighted, so you may want to spend more time reviewing them. The breakdown appears in the following table. Percentage Breakdown of NCLEX-RN Content Client Need Category Percentage of Test Safe and effective care Management of care 17–23% Safe and effective care Safety and infection control 9–15% Health promotion and maintenance N/A 6–12% Psychosocial integrity N/A 6–12% Physiological integrity Basic care and comfort 6–12% Physiological integrity Pharmacological and parenteral therapy 12–18% Physiological integrity Reduction of risk potential 9–15% Physiological integrity Physiological adaptation 11–17% Client need #1: Safe and effective care The first client need, safe and effective care, includes nursing care that addresses anything that falls under management of care and safety and infection control. Management of care covers Advance directives/self-determination and life planning Advocacy Assignment, delegations, and supervision Case management Client rights Collaboration with the multidisciplinary team Concepts of management Confidentiality/information security Continuity of care Establishing priorities Ethical practice Informed consent Information technology Legal rights and responsibilities Performance improvement Referrals Safety and infection control covers Accident prevention/error/injury prevention Emergency response plan Ergonomic principles Handling hazardous and infectious materials Home safety Reporting of the incident event/irregular occurrence/variance Safe use of equipment Security plan Standard precautions/transmission-based precautions/surgical asepsis Use of restraints and safety devices Here’s an example question that falls under this first client need category: Practice question The nurse is making an assignment for the nursing assistant who has been floated to the unit for the shift. Which of the following assignments would be appropriate for a nursing assistant? (1) A 62-year-old with a fractured hip, four days post-op (2) A 75-year-old admitted three hours ago with intermittent chest pain (3) A 49-year-old, one day post-op bowel resection, NPO with a nasogastric tube (4) A 50-year-old who is being discharged The correct answer is Choice (1). Keywords are assignment, for nursing assistant, floated, and appropriate assignment. What do you remember about delegation? What are the rules of how to delegate patient assignments? The nursing assistant can perform all activities of daily living, which include bathing, feeding, mobilizing, toileting, and basic comfort. The LPN can provide all the activities of daily living as well as skills that require sterile techniques, medication administration, invasive procedures, and treatments. The RN can do all the activities of daily living, all the skills, and all the assessments and teaching. Knowing about delegation makes it really easy to determine the correct answer. The nursing assistant can’t be assigned any patient who requires skilled care, assessment, or teaching. Therefore, the most appropriate patient to assign to the nursing assistant is the most stable patient who doesn’t need any medications, assessment, treatments, or teaching. Any patient who’s being admitted or discharged must always be assigned to the RN. Client need #2: Health promotion and maintenance The second client need, health promotion and maintenance, includes all things pertaining to the health in a person’s life — prevention and care out of the hospital and all things concerning a normal pregnancy and delivery, among other things. Health promotion and maintenance covers Aging process Ante/intra/postpartum and newborn care Developmental stages and transitions Health promotion/disease prevention Health screening Family Planning High-risk behaviors Human sexuality Immunizations Lifestyle choices Principles of teaching and learning Self-care Techniques of physical assessment Questions in this category may be worded like so: Practice question The mother of a 2-month-old brings her baby to the well-baby clinic for his first health assessment. Which of the following would be appropriate anticipatory guidance for the nurse to present to the mother? (1) “Start using your car seat as soon as he can hold his head steady.” (2) “Begin adding cereal to his formula.” (3) “Expect him to begin to go for longer periods in between feedings.” (4) “Consider taking him to play groups for additional stimulation.” The correct answer is Choice (3). The keywords here are 2-month-old, well baby clinic, first health assessment, and appropriate anticipatory guidance for mother. By 2 months of age, babies’ stomachs have grown enough to accommodate larger feedings, which allow them to go for longer stretches before needing refueling. A 2-month-old should already be using a car seat. Cereal isn’t added until the child is at least 4 months old (around the same time that teeth erupt), and a 2-month-old is only interested in his primary caregivers. Client need #3: Psychosocial integrity The psychosocial integrity category tests your knowledge of culture, health practices, mental health disorders, addictions, crisis theory, and the foundations of mental health nursing. This section is all about feelings and emotions and how to get the client to express them to be therapeutic. Psychosocial integrity covers Abuse/neglect Behavioral interventions Coping mechanisms Crisis intervention Cultural awareness/cultural influences on health End of life care Family dynamics Grief and loss Mental health concepts Religious and spiritual influences on health Sensory/perceptual alterations Stress management Substance use and dependencies Support systems Therapeutic communications Therapeutic environment The following is an example of a question addressing this client need: Practice question A nurse is providing information to the family of an alcoholic patient. The nurse encourages the wife of the patient to attend an Al-Anon support group. The wife states that it’s difficult for her to face other people because she is embarrassed by her husband’s behavior. What would the nurse most appropriately tell a wife to help alleviate some of her concern? (1) She doesn’t need to tell anybody her name or other identifying information. (2) She won’t know any members of the support group. (3) The members of the group have all experienced the same problem. (4) The group is always led by a nurse, physician, or other healthcare provider. The correct answer is Choice (3). Keywords to look at are wife of alcoholic patient, attending Al-Anon meetings, embarrassed by husband’s behavior, and most appropriate to alleviate some of her concerns. This question relates to supporting the client’s wife during an embarrassing event. Al-Anon is a support group for spouses and friends of alcoholics or addicts of any kind. Support groups are based on the premise that people who have experienced a problem are able to help others with the same problem. Choice (2) is wrong because the nurse can’t be sure that the spouse won’t know anybody in the group. Although Choice (1) may be correct, it’s not the most appropriate response to give to the wife of this patient. Choice (4) is incorrect because, although a nurse or other healthcare professional may be asked to speak at a group meeting, the members of the support group usually lead it themselves. Client need #4: Physiological integrity The last client need, physiological integrity, includes four different subcategory client needs: basic care and comfort, pharmacological and parenteral therapies, reduction of risk potential, and physiological adaptation. Basic care and comfort addresses the knowledge, skills, and ability required to provide comfort and assistance to the client in the performance of activities of daily living. Pharmacological and parenteral therapies address the knowledge, skills, and ability required to administer medication and other intravenous therapies. Reduction of risk potential addresses the knowledge, skills, and ability required to prevent complications or health problems related to the client’s condition or any other prescribed treatment or procedures. Physiological adaptation addresses the ability to provide care to clients with acute, chronic, or life-threatening conditions. In the category of physiological integrity, you’ll encounter questions from the following subcategories: Basic care and comfort covers Assistive devices Elimination Mobility/immobility Non-pharmacological comfort interventions Nutrition and oral hydration Personal hygiene Rest and sleep Pharmacological and parenteral therapies covers Adverse effects/contraindications and side effects Blood and blood products Central venous access devices Dosage calculation Expected outcomes/effects Intravenous therapy Medication administration Parenteral/intravenous fluids Pharmacological pain management Total parenteral nutrition Reduction of risk potential covers Changes/abnormalities in vital signs Diagnostic tests Laboratory values Monitoring conscious sedation Potential for alterations in body systems Potential for complications of diagnostic tests/treatments/procedures Potential for complications from surgical procedures and health alterations System specific assessments Therapeutic procedures Physiological adaptation covers Alterations in body systems Fluid and electrolyte imbalances Hemodynamics Illness management Medical emergencies Pathophysiology Unexpected response to therapies The following is an example question addressing the physiological integrity client need: Practice question Which of the following would the nurse expect to be interventions for a client with acute kidney disease? Select all that apply (1) I & 0 every two hours for color and characteristics (2) Sodium bicarbonate to be used if acidosis occurs (3) Monitor for wheezing, rhonchi, and edema, which is an indication of fluid retention and overload (4) Daily weight (5) Monitor urinalysis for hematuria, casts, specific gravity, and glucose levels The correct answers are Choices (2), (3), and (4). Keywords are nurse expect, interventions, and acute kidney disease. This question addresses the subcategory of physiological adaptation. Because it asks which interventions would be expected for acute kidney disease, Choice (1) is incorrect; it has the nurse monitoring I & 0 every two hours, when the monitoring should actually occur every hour. Choice (2) is correct because you’d monitor for acidosis and treat with sodium bicarbonate. Choice (3) is correct because wheezing, rhonchi, and edema are all signs of fluid overload. Choice (4) is correct because taking daily weights to check for weight gain — a sign of fluid overload if greater than 2 pounds in 24 hours — is appropriate for this condition. Choice (5) is incorrect. You’d monitor urinalysis for all but the glucose in acute kidney disease.

Article / Updated 09-21-2020

Did you hear that more people pass the NCLEX-RN on Thursdays than on Fridays? Did you know that you don’t stand a chance of passing if your name has an R in it? These are just a few of the wild — and false — rumors and myths that surround the NCLEX-RN exam. Length of the NCLEX-RN exam matters More people agonize over when the test “shuts off” than any other topic concerning the NCLEX-RN. Rumor says that if your test stops at 75 questions, you’ve passed, and if you get 265 questions, you’ve failed. (You may also hear the reverse — fewer questions equal failure and more questions equal passing.) The truth is that the length of your test has nothing to do with whether you pass or fail. The number of questions you get is based on how you answer the questions. If you answered correctly, a harder question is given to you. If you answer incorrectly, an easier question is given to you. The NCLEX-RN uses a program called Computer Adaptive Testing (CAT), which assesses a test taker’s abilities (as in whether you can answer difficult questions correctly or only simple ones) based on his or her answers to exam questions and searches its bank of test questions for questions that are equal to the test taker’s abilities. The fact that the NCLEX-RN uses CAT means that, depending on your performance, you may answer fewer questions than you’d have to answer on other types of tests that determine your knowledge of safe and effective nursing care. Although the exam doesn’t have a time limit for each question, keep a steady pace and try to spend about one minute on each question. Every NCLEX-RN question counts This point may sound like a reasonable assumption for any exam, but for the NCLEX-RN, it’s false. The NCLEX-RN uses you as a guinea pig to try out new questions that aren’t yet part of the scored test. Each candidate’s exam contains up to 15 experimental questions, but, tricky devils that they are, the exam folks don’t tell you which ones are the experimental items. So, despite the myth, treat every question as if it counts, even though it really may not, to be on the safe side. Computer savvy is essential You don’t have to be a computer whiz to take the NCLEX-RN. When you show up for the exam, the test administrator conducts an orientation, and you work through a tutorial that explains how to use the keys and how to record your answers. (When taking the exam, you only use two keys: the space bar to move the cursor and the enter key to highlight and lock in your answer.) The tutorial also covers how to respond to questions that may use a format other than multiple choice. You’re allowed to ask the test administrator for help if you have trouble with the computer during the test. You can’t stop ’til you’re done After you sit down at the computer to take the NCLEX-RN, two breaks are prescheduled. The first break comes after 2 hours of testing, and the second break comes after 3.5 hours of testing. (You have up to 6 hours to take the test, though most test takers finish in 2.) The computer even tells you when you can take a break, so all you have to do is focus on the test. Taking a break at prearranged times or times you chose, counts against your testing time, so don’t overdo it. But if you need a quick breath of fresh air and a stretch, a few minutes away from the test may be worth it. Clearing your head and relaxing your body may be just what you need to keep your momentum going, your brain sharp, and your anxiety at bay. You take breaks outside the testing room, and the test administrator makes sure you follow all the rules and get back to your test without any problems. The NCLEX-RN test plays off your weakness The NCLEX-RN isn’t out to get you. When you answer a question incorrectly, the computer automatically chooses an easier question for you to answer. If you answer that question correctly, it chooses a slightly more difficult question. Throughout the exam, the computer gives you questions based on your answer to a previous question’s difficulty level. What the computer is trying to establish is your competence level, or ability to correctly answer approximately 50 percent of the questions you’re given, which means you need to be above the passing standard consistently to show competency. The computer is able to establish your competence level after a minimum number of questions. It then compares your competence level to the passing standard competence level and makes one of the following assessments: You’re above the passing standard. You pass, and the test ends. You’re below the passing standard. You fail, and the test ends. You’re close to the passing standard, but it’s still not clear whether you should pass or fail. You continue answering questions until either the computer can make the determination of whether you should pass or fail or the time runs out. The NCLEX-RN tries to give you every opportunity to demonstrate that you have the knowledge, judgment, and skill to get that license. This type of testing actually improves your chances of demonstrating a passing score. You have to wait eons to retake a failed test The waiting period for retesting is 45 days. This period gives you enough time to continue studying and reviewing, but you don’t have to wait so long that the knowledge you have becomes obsolete. If you fail the exam at any point, the state’s board of nursing sends you a Candidate Performance Report (CPR). This report summarizes your strengths and weaknesses based on the NCLEX-RN test plan, breaking down whether you were above, near, or below passing standard in a given area. (The preceding section explains what these standards mean.) This information is very helpful because it lets you know exactly what you need to study so that you don’t waste precious time studying what you already can demonstrate knowledge of. Your first instinct is probably wrong The NCLEX-RN doesn’t allow you to go back and review the questions you’ve already answered. When you submit an answer, it’s gone forever. The ability to only move forward prevents that pitfall of reconsidering and changing your answers and, in the process, losing precious time. The questions are presented one at a time, and you can review each one for as long as you want before you submit your answer. You must confirm your submission before you can go on to the next question, so you can be sure of your choice. You can change your answer before you submit it, but keep in mind that you’re most likely to choose the correct answer right off the bat because you make the choice calmly and rationally. When you change your answers, you’re second-guessing yourself, which leads to uncertainty and doubt that just balloons until you aren’t sure about anything anymore. That’s definitely not a good way to make a correct decision. So read the question, find your keywords, analyze your answers, and then choose your answer based on what you see in the question and know about the content being tested. If you’re having a “could-be” or “might-be” conversation with yourself, move on and leave your first answer as it is. The same question popped up twice The NCLEX-RN doesn’t contain repeat questions, so you won’t see the same question more than once. You may receive a question that contains similar symptoms or diseases to another question but actually addresses a different area of the nursing process. Don’t assume that you receive a similar question because you answered a previous question incorrectly. Some items on the test are trial questions. Seeing two similar questions may (or may not) indicate you’ve gotten one of those experimental items. Always choose the best answer for each question; don’t select an answer based on information you may have seen in a previous question. Your test schedule chooses you You can choose not only your test date but also the time you want to take your test. This control gives you the upper hand in scheduling yourself for success. After you receive your Authorization to Test (ATT) from the board of nursing in the state in which you’re taking your exam, you can schedule your test date and time. Don’t wait to schedule, though, because the longer you wait, the less likely you are to get the schedule you want. If you’re a first-time test taker, you’re offered an appointment within 30 days; if you’re a repeat test taker, you will be offered an appointment after 45 days. You may choose to make an appointment later than what you’re offered, but make sure you stay within your ATT time frame when you schedule. Otherwise, you lose that attempt. By choosing your own test schedule, you ensure that the day of your test doesn’t conflict with anything else you may have scheduled. Schedule your test so that you have a six-hour window. Keep in mind that the NCLEX-RN session can last up to six hours (including orientation). Choice (3) is the magic answer, and other multiple-choice fails Conventional wisdom claims that multiple-choice tests use Choice (C) as a correct answer more than any other answer choice. In the language of the NCLEX-RN, Choice (C) translates to Choice (3), but the fact remains that the correct answers don’t follow any particular pattern. The chance of the correct answer to any NCLEX question being Choice (3) is no better than the correct answer being Choice (1), Choice (2), or Choice (4). Another trap: When test takers don’t know the answer to a question, they tend to choose the answer option that they know nothing about. They assume that if they don’t know what it is, it must be the right answer. Nothing could be more incorrect. If you can’t determine the correct answer, your best option is to choose an answer option that you know something about. When you’re unsure of the correct choice, choosing something you know is an educated guess, and it may be correct.

Article / Updated 09-21-2020

When you’re studying for a nursing exam, you can’t go wrong if you start with Abraham Maslow, the creator of Maslow’s hierarchy of needs, a laundry list of what people need most in life. Maslow will be your best friend when you take the NCLEX-RN. Maslow’s hierarchy has it all. If you follow Maslow, your nursing care will be organized by priority, with the really important things — like the need to be breathing — always at the top of the list. Setting priorities is a much bigger part of nursing than it may seem to you right now. Take my word for it: The ability to set priorities not only helps keep your future patients alive but also helps you finish your charting on time. Know Maslow well — and put him first in every situation. Maslow divided the needs of people into six incremental stages, from most important to least important. Maslow’s needs are arranged in the form of a pyramid, with physiological needs (what everyone needs to live) on the bottom, holding everything else up, so to speak. After all, if you can’t breathe, you can’t have a new house or be a best-selling author because you’re dead. Everyone achieves the needs at the bottom of the pyramid, but not everyone achieves the needs at the top. Notice that all needs are important, but some are way more important than others. This point is essential to remember not only on the exam but also when you’re working as a nurse and have to prioritize your six patients’ 101 needs in order of importance. For example, giving someone a bed bath is never as important as suctioning someone with a clogged endotracheal tube. NCLEX-RN questions love to test your ability to prioritize in nursing situations. “What should you do first?” is a question you see frequently on the test. Obviously, you should first do what’s most important, and what’s most important is found in Maslow’s hierarchy at the bottom of the pyramid. Here are some quick guidelines for setting priorities in nursing care: Nurses decide priorities by assessing and analyzing. To assess priority, start with the ABCs — airway, breathing, circulation, or most life-threatening— and Maslow’s hierarchy. Priorities can be high, intermediate, or low. Treating potentially life-threatening problems before they become life-threatening is a high priority. Non-life-threatening needs are intermediate priorities. Low-priority needs are needs that aren’t related to the patient’s diagnosis. Always consider time and resources as laid out in the question. If the patient considers a problem important, then it is.

Article / Updated 09-21-2020

Everyone needs to live in balance, but the body especially does because minor shifts in any system can cause major problems. This article dives into the issue of imbalance and looks at the kinds of questions you may see on the NCLEX-RN. You need to know the body’s requirements for proper vitamins and proper treatment of disease in addition to the signs and symptoms of major diseases. What to do when the body systems are out of whack Any body system can be altered for better or worse, so this section is a very broad topic. Remember that the main body systems include cardiac, respiratory, endocrine, neurologic, musculoskeletal, immune, genitourinary, gastrointestinal, reproductive, and integumentary. When prioritizing care for alterations in any body system, always remember to put physiological needs first. Test questions on body system alterations include questions on adults and children. Here are some examples: Practice question A client comes into the emergency room with complaints of dizziness, nausea, and vomiting. The doctor suspects Ménière’s disease. What is the nurse’s priority action? (1) Give an antiemetic (2) Initiate a sodium-restricted diet (3) Give an antihistamine (4) Initiate safety measures The keywords in this question are emergency room; dizziness, nausea, and vomiting; Ménière’s disease; and nurse’s priority action. The correct answer is Choice (4). A Ménière’s patient is at high risk for falls; therefore, safety measures need to be put in place. The other answers are interventions for this condition but aren’t a priority at this time. Practice question A 21-year-old client has just been diagnosed with having a hydatidiform mole. Which of the following is considered a risk factor in developing this mole? (1) Age in 20 to 40 range (2) Primigravida (3) Prior molar gestation (4) High socioeconomic status The keywords for this question are 21-year-old client, hydatidiform mole, and risk factor in developing this mole. The correct answer is Choice (3). Prior molar gestation increases a woman’s risk for developing another molar gestation. Adolescents and women 40 and older are also at increased risk for molar pregnancies. Multigravidas, especially women with prior loss of pregnancies and women from lower socioeconomic classes, are at an increased risk. Practice question When performing a neurologic assessment on a neonate, which sign is considered a normal finding? (1) A positive Babinski’s sign (2) “Sunset” eyes (3) Closed fontanels (4) Pupils unreactive to light Keywords for this question are performing a neurologic assessment, neonate, and normal finding. The correct answer is Choice (1). A positive Babinski’s sign is normal in infants up to one year of age but is abnormal in adults. Sunset eyes, where the sclera is visible above the iris, is a result of cranial nerve palsy and may indicate increased intracranial pressure. Fontanels do not completely close till 18 months. An infant’s pupils react to light in the same way that an adult’s pupils do. Practice question Crohn’s disease is a chronic relapsing disease. Which area of the GI tract is involved with this disease? (1) The entire length of the large intestine (2) The small intestine and colon, the entire thickness of the bowel (3) The small intestine, mucosa only (4) The sigmoid area only The keywords for this question are Crohn’s disease, chronic relapsing disease, and which area of the GI tract is involved. The correct answer is Choice (2). Crohn’s disease may involve the large intestine, the small intestine, or both, and it affects the entire thickness of the bowel regardless. Choices (1) and (3) probably describe ulcerative colitis, and Choice (4) is too specific and a small part of the bowel; therefore, it isn’t a likely answer. In any body system alteration, when an answer involves a very specific part of the body, it’s probably an incorrect choice. Practice question When assessing a client with a history of genital herpes, which of the following symptoms would indicate that an outbreak of lesions is imminent? (1) Headache and fever (2) Vaginal and urethral discharge (3) Dysuria and lymphadenopathy (4) Genital pruritis and paresthesia The keywords for this question are assessing a client, history of genital herpes, and following symptoms would indicate that an outbreak of lesions is imminent. The correct answer is Choice (4). Pruritis and paresthesia, as well as redness of the genital area, are symptoms of recurrent herpes infection. These symptoms appear anywhere from immediately before lesions appear to 48 hours prior. Headache and fever are symptoms of primary infection. Dysuria and lymphadenopathy are local symptoms of primary infection that may occur with recurrent infection, but don’t occur prior to the outbreak of lesions. Infection Infection is an invasion of the body by pathogenic organisms that multiply and produce injurious effects. A communicable disease is an infectious disease that may be transmitted from one person to another. To prevent the spread of infection, you need to break the chain of events that leads to infection by doing the following: Maintain a clean, dry, well-ventilated environment. Wash your hands — yes, between every client! Disinfect, maintain isolation when necessary, and use aseptic techniques. Use universal precautions — on everyone! (That’s why they’re called “universal.”) You also need to remember treatment protocols, antibiotics and other drug therapy and contraindications, and how to prevent the continued spread of disease. Everything that happens, whether it’s related to nursing or not, starts with a chain of events. See the following figure for a visual example. The following are typical questions related to infectious disease: Practice question Which of the following types of cases of pneumonia is most common in children ages 5 to 12? (1) Enteric bacilli (2) Mycoplasma pneumonia (3) Staphylococcal pneumonia (4) Streptococcal pneumonia Keywords for this question are types of cases of pneumonia and most common in children ages 5 to 12. The correct answer is Choice (2). Mycoplasma pneumonia is typically seen in older children. The other three are typically seen in children from 3 months to 5 years old. Practice question Pneumococcal vaccine polyvalent and flu vaccination are highly recommended for clients with asthma, chronic bronchitis, and emphysema for which of the following reasons? (1) These vaccines prevent the patient from getting pneumonia or other serious respiratory infections. (2) These vaccines help reduce the fast respiratory rates that these clients experience. (3) These vaccines help reduce the need for maintenance medications for these conditions. (4) All clients should have these vaccines. The keywords for this question are pneumococcal and flu vaccination; recommended for clients with asthma, chronic bronchitis, and emphysema; and for which of the following reasons. The correct answer is Choice (1). Receiving vaccines to protect against respiratory infection is highly recommended for clients with respiratory disorders. Infections can cause these clients to need intubation and mechanical ventilation. Weaning may be difficult or impossible because the client’s respiratory system becomes dependent on the assistance provided by the ventilator. The vaccines have no effect on bronchodilation or respiratory rate. Practice question An adult client has received an injection of immunoglobulin. The nurse knows that the client will develop which of the following types of immunity? (1) Active natural immunity (2) Active artificial immunity (3) Passive natural immunity (4) Passive artificial immunity Keywords for this question are adult client, injection of immunoglobin, and develop which of the following types of immunity. The correct answer is Choice (4). Passive artificial immunity occurs when antibodies are produced by another person or animal and injected into the recipient. Practice question A patient is being admitted to the unit with a diagnosis of chickenpox, or varicella. The nurse needs to set up which transmission-based precautions for this patient? (1) Droplet (2) Contact (3) Airborne and contact (4) Standard This question’s keywords are a diagnosis of chickenpox, or varicella; needs to set up; and which transmission-based precautions. The correct answer is Choice (3). Chickenpox is transmitted by touching the rash or contaminated objects and by droplets.

Article / Updated 09-21-2020

Patients undergoing tests and therapy require nursing care during and after their procedures. For the NCLEX-RN exam, you need to know what’s necessary to maintain patient safety during the medical test and physiological integrity after the therapy or procedure. Facing an MRI, the hot potato of medical tests When you think of having an MRI, what’s the first thing that comes to mind? If you thought “claustrophobia,” you’re on the same wavelength as many of your future patients. Many patients have a fear of being enclosed in an MRI, but claustrophobia isn’t the only thing that can cause chaos in an MRI. Magnetic resonance imaging (MRI) uses magnetic and radio waves to create a detailed visualization of the brain, heart, and other body structures. Pacemakers and surgical or orthopedic clips can wreak havoc with the patient — and the equipment. (Shrapnel shouldn’t be scanned, either, so be sure that you have a complete history!) Always remove jewelry and metal objects from the patient prior to the procedure, and always determine the patient’s ability to lie still and the possibility that he or she may become claustrophobic. Here’s an example of questions related to patient tests: Practice question A client is scheduled for magnetic resonance imaging (MRI) of the head. Which of the following areas is essential to assess before the procedure? (1) Food and drink intake within the past eight hours (2) The presence of metal fillings, prosthesis, or a pacemaker (3) The presence of carotid artery disease (4) Voiding before the procedure Keywords for this question are MRI of the head and essential to assess before the procedure. The correct answer is Choice (2). Strong magnetic waves may dislodge metal in the client’s body, possibly causing injury. Although the client may be told to restrict food intake for eight hours prior to the procedure, particularly if contrast will be used, metal is an absolute contraindication for this procedure because it’s a safety issue. Voiding beforehand makes the client more comfortable and better able to remain still during the procedure, but it isn’t essential for the test. And carotid artery disease isn’t a contraindication. Handling therapies, from dialysis to radiation There’s no end to therapy when you’re a nurse. Types of therapy include chemotherapy, radiation, physical and occupational therapy, respiratory therapy, dialysis, and dozens of others. Every type of therapy has both an expected and unexpected outcome; you need to be aware of both the potential positive and negative outcomes so that you know what to look for when administering therapy to a patient. You also have to know the what, why, and how of therapy: What is this therapy expected to do for this patient? Why does the patient need it? What’s gone wrong that needs to be corrected? And how does this therapy accomplish that? Questions on therapies usually focus on radiation and chemotherapy. Tuck away the following facts, and you’ll be well prepared for these types of questions: When it comes to radiation: Side effects are cumulative. The effects appear after the total dose exceeds the body’s ability to repair damage caused by radiation. Fatigue is one of the most common side effects of radiation and often isn’t relieved by rest. Other side effects of radiation include skin problems, anorexia, nausea, vomiting, diarrhea, anemia, leucopenia, and thrombocytopenia. Physical therapy can be draining for the patient, and interventions are coordinated as necessary around patient needs. When it comes to chemotherapy: Chemo is a balancing act based on the ability of a drug to kill cancer cells while damaging normal cells as little as possible. The destruction of normal cells leads to numerous side effects that affect body systems, including but not limited to GI, hematologic, integumentary, renal, reproductive, and neurologic systems. The effect of chemotherapy is greatest on rapidly dividing cells, such as bone marrow cells, GI tract, and hair. Other therapies, such as wound therapy, may show up in questions related to pressure ulcers and nursing management. You can also expect questions on cardiovascular disorder interventions such as percutaneous transluminal coronary angioplasty (PTCA), coronary artery stents, atherectomy, coronary artery bypass graft (CABG), and cardiac transplant. I simply don’t have the space to list all the main facts about all these therapies, so refer to your textbooks for a refresher. The following are some examples of questions related to patient therapy: Practice question The client is undergoing radiation therapy to treat lung cancer. Following the treatment, the nurse notes erythema on the client’s chest and neck, and the client is complaining of pain at the radiation site. The nurse interprets this data to mean (1) A superficial injury to the tissue from the radiation (2) An allergic reaction to the radiation (3) A cutaneous reaction to products formed by the lysis of the neoplastic cells (4) An ischemic injury, much like decubitus formation, caused by pressure from the machine Keywords for this question are undergoing radiation therapy, treat lung cancer, erythema on the client’s chest and neck, complaining of pain at the radiation site, and nurse interprets. The correct answer is Choice (1). Superficial injury from radiation can manifest with erythema, hyperpigmentation, dry desquamation, or moist desquamation. Moist desquamation is comparable to a second-degree burn in histology, appearance, and sensation. Note the relationship between erythema in the question and the reference to superficial injury in the correct response. Practice question A nurse is evaluating a client’s response to cardioversion. Which of the following observations would be of the highest priority to the nurse? (1) Oxygen flow rate (2) Status of the airway (3) Blood pressure (4) Level of consciousness Keywords in this question are evaluating the client’s response to cardioversion, observations, and the highest priority to the nurse. The correct answer is Choice (2). Nursing responsibility after cardioversion is the maintaining the airway first, followed by administering oxygen and assessing vital signs and level of consciousness. Noting the key phrase “highest priority” prompts you to refer to the ABCs and use the process of elimination to reach the correct answer. Practice question A client is admitted to the emergency department with an active diagnosis of acute myocardial infarction. The patient is started on tissue plasminogen activator (tPA) by infusion. Which of the following parameters would a nurse determine requires the least frequent assessment to detect complications of therapy with tPA? (1) Oxygen saturation (2) Neurological signs (3) Blood pressure and pulse (4) Complaints of abdominal and back pain Keywords in this question are an active diagnosis of acute myocardial infarction, tissue plasminogen activator, which of the following parameters requires the least frequent assessment, and detect complications of therapy. The correct answer is Choice (1). An acute myocardial infarction is due to a clot or plaque blockage, and the drug is given to break up clots. So your priority is bleeding. The key phrase here is least frequent assessment. Thrombolytic agents dissolve clots, and bleeding can occur anywhere in the body. The nurse monitors for any signs of bleeding and also for occult (hidden) signs of bleeding by taking hemoglobin and hematocrit values, blood pressure, and pulse; checking neurological signs; assessing abdominal and back pain; and checking for the presence of blood in the stool and/or urine. Bleeding is the primary complication of thrombolytic therapy. The preceding question requires you to set priorities. A change in neurological signs can indicate cerebral bleeding, abdominal and back pain can indicate abdominal bleeding, and change in blood pressure and pulse can be general indicators of hemorrhage. Oxygen saturation isn’t an indicator of bleeding in the respiratory tract. Practice question A client has moist saline dressings applied to an open ulcer of the foot. Ten days after ulcer development, the wound should have which appearance? (1) Red, swollen tissue (2) Dry, crusted scab (3) Deep, wide keloid (4) Warm, painful tissue Keywords for this question are moist saline dressings, open ulcer of the foot, ten days after ulcer development, and should have which appearance. The correct answer is Choice (2). Ten days into healing, an ulcer should be at the end of the lag phase of healing, as indicated by a dry, crusted scab. The tissue is red, swollen, warm, or painful during the inflammatory period, which occurs two to seven days after the ulcer develops. A deep, wide keloid may appear three weeks to two years after ulcer development. Practice question Which of the following treatments is a suitable surgical intervention for unstable angina? (1) Cardiac catheterization (2) Echocardiogram (3) Nitroglycerin (4) Percutaneous transluminal coronary angioplasty (PTCA) The keywords for this question are suitable surgical intervention and unstable angina. The correct answer is Choice (4). Angina is caused by a blockage, so look for an answer choice that would open the blockage. PTCA can alleviate the blockage and restore blood flow and oxygenation. An echocardiogram is a noninvasive diagnostic test. Nitroglycerin is an oral or sublingual medication. Cardiac catheterization is a diagnostic tool, not a treatment. Practice question A client has been to hemodialysis. Which of the following should the nurse be alert to for complications? Select all that apply. (1) Fluid volume excess (2) Disequilibrium (3) Hemorrhage (4) Shock (5) Air emboli Keywords for this question are has been to hemodialysis and alert to for complication. The correct answers are Choices (2), (3), (4), and (5). Disequilibrium, hemorrhage, shock, and air emboli are all complications of hemodialysis. Hemodialysis takes fluid off, so Choice (1) is incorrect.

Article / Updated 09-21-2020

Every test has rules, and the NCLEX-RN is no exception. The 10 rules that make up this list don’t come from a rule book, however. They come from years of experience with the NCLEX-RN, and I chose them specifically to help you focus on what can really help you succeed on the exam. Follow these 10 rules as you get ready for and take the exam, and you’ll be well on your way to putting “RN” after your name! Read each question in its entirety When you read a question, you may identify a keyword or phrase right away and think you know the answer. You check out your four answer options; see the answer that you came up with; say to yourself, “That was easy”; and choose that perfect answer. But if you were to read the question more carefully, you may see that your perfect answer doesn’t really answer the question — it just seems like it does. Sometimes all the answers are right and you must choose the best one. Speed-reading questions and jumping to answers isn’t an effective way of identifying the real problem the question is presenting and often leads you to an incorrect answer. The best approach is to read the entire question at least once before reading the answers. Take the opportunity to think about what the question is asking before you rush to the answers. Part of the skill required for success on this exam is reading comprehension, so read carefully and thoroughly. And make sure you read all of the answer, too, checking carefully for any bits that are wrong. Don’t read into the question Many students fall victim to the pitfall of thinking too deeply about a question and inserting bits and pieces that aren’t actually in the question. Adding information to a question— from words to responsibilities and situations — is deadly. It almost always encourages you to choose an incorrect answer because your mind is already heading in one direction. Instead of reading into a question, take the information in the question and choose an answer that best reflects the stated problem. For example, you may read a question that asks a nurse to complete a very time-consuming task. You may ask yourself, “How could I possibly have time to complete that task when I have six other patients to care for?” Well, the question never presented any other patients in the scenario. If the question asks you about one patient and doesn’t tell you that you’re responsible for any others, don’t assume that you have that responsibility — just answer the question. Answer questions with the ideal situation in mind One tried-and-true characteristic of the NCLEX-RN is that all the questions reflect nursing practice in a perfect world, which is majorly different from the NCLEX-RN world. On the day of the test, remember that the real world doesn’t belong on the NCLEX-RN. When you read a question and its answer options, ask yourself, “If all conditions were optimal, what would I choose to do?” Follow all the steps you learned in nursing school regardless of how time-consuming or laborious they may seem. The exam is testing your knowledge of how you’d provide care for a patient under the most optimal circumstances. Many students choose an incorrect answer even though they’ve identified a better and safer choice; they say to themselves, “I saw a nurse do that in clinical, and if an experienced nurse does it that way, then how could I know better?” The truth is, most new graduates practice safer nursing care because they follow all the steps in the process and don’t take shortcuts. Don’t use what you see other nurses do at work. The people who write the exam are aware of how many nurses in practice may take shortcuts to save time but also may put the patient at risk. Therefore, they test to make sure you aren’t taking any shortcuts. Always choose an answer that includes all the steps in a process in the correct sequence. Avoid changing your answers Most students change their answer to a question only to find out that they changed a correct answer to an incorrect answer. Second-guessing yourself is probably one of the most dangerous things you can do on a test. Students change answers because they don’t trust their judgment or knowledge about a subject. As a new nurse, you probably don’t have much experience to draw on, so when faced with a situation in which making a choice confirms your decision about how to handle a particular situation, you may feel that you aren’t “qualified” to make that decision. You couldn’t be more wrong. By virtue of your graduation from nursing school, you’re qualified to make the decisions that new graduate nurses are allowed to make. The exam asks only questions that are within the scope of practice of a new graduate, not of an experienced ICU nurse. Nursing schools are very careful about making sure that all graduates are able to safely and competently make the decisions necessary to care for patients. Your first choice is usually well thought out and rational; changing your answer indicates doubt and insecurity. Be confident in your instincts! Don’t call the doctor until you’re sure you need to Calling the patient’s doctor is always a tempting choice because, after all, who better to make patient care decisions than the doctor? However, the NCLEX-RN examiners have prepared this test as a nursing practice test and are testing you on what a nurse would do in a particular situation, not what a doctor would do. Doctors have their own tests! Besides, anytime you call a doctor, he or she asks questions about the patient, such as what vital signs and symptoms you’ve observed and what actions you’ve taken to address the problem. Always think about what appropriate nursing actions would be important to implement before calling the doctor, and you have your answer. Also remember to consider what you can do to help this patient prior to calling the doctor. The doctor won’t magically appear when called; getting there takes time. Can you do something in the meantime? Both scenarios help you find your answer. Avoid answers that make you choose all or nothing Very few things happen either all the time or none of the time. Life’s just not like that. Even if you want things to be black and white, they never are. So avoid choosing answers that include specific, finite words like all, every, always, none, and never. These words should be a red flag that the answer has some flaw. Rarely can you describe a situation in such concrete terms. Even if the rest of the answer seems possible and only that one little word gives you doubt, the fact that the situation is presented in an all-or-nothing way makes it very unlikely to be correct. Nurses must be prepared to function in an ever-changing environment, so answers with words that indicate the flexibility of a situation are more likely to be correct. Don’t memorize facts, questions, or other useless trivia Memorizing a lot of factoids, questions, and other information is a lot of work and very time-consuming. It exhausts you and takes up time that you could spend studying the really important stuff. Anyway, questions in books or in online testing for the NCLEX-RN never show up word for word. Memorizing them isn’t worth your time. You may see a question with the same content, but it’s likely to be asking something completely different than the question you memorized. Knowledge and understanding of content is a much more successful path to take; believe it or not, actually learning the information doesn’t take any longer than memorizing it. The main difference is that the information you learn and understand stays in your head much, much longer than what you memorize by rote. And you can apply learned information to many different situations, which enables you to answer so many more questions correctly. A little knowledge can go a long way. Don’t think you can be ready without hard work Many new graduates and NCLEX-RN candidates are accustomed to cramming for exams. In nursing school, you may have only had a few weeks to prepare for a test in a particular course because the next test was just around the corner. Well, cram no more — you can take more time to prepare for the NCLEX-RN than any other test you took in nursing school. This is the test — the last test you need to take prior to receiving your nursing license — so you can spend all your study time preparing for only this test. I recommend that you begin to study as soon as you graduate. Continue to review your notes and study your textbooks every day until you actually take the test. Don’t leave long gaps in your study schedule. As time goes on, most people tend to forget more, not remember more; continuous review and practice keeps much of that precious nursing knowledge in your head until the big day. Know your strengths and weaknesses As you prepare yourself for the NCLEX-RN, you should take as many practice tests as you can. Practice tests reveal two things: Content areas that you need to spend more time reviewing Test-taking strategies that you need to brush up on Going over your answers and understanding the rationales for the correct answers helps you identify your weak areas content-wise, and identifying areas that you’re good at relieves you from studying what you already know. You free up your study time to focus on things that need the most work. Write down the content you missed on practice tests, and any other content on that topic you don’t know. Review this content at least daily to limit the number of times you look up a specific subject. “One and done” is my motto. Be kind to yourself For many, taking the NCLEX-RN is so overwhelming that it seems more like a punishment than a reward. Remember, taking the NCLEX-RN is a reward for successfully completing nursing school. Therefore, you should treat yourself extra well during the time you spend preparing for this exam. Many people lock themselves away from family and friends and just study day and night. But that approach may not be as beneficial as you think. Having the support of those who are closest to you and care most about you makes the triumph of passing much sweeter. Taking good care of yourself during preparation time ensures that you have maximum energy and can get the most out of the hard work you put in. Continue all your regular healthy habits, like exercising, eating right, sleeping well, and, most of all, taking some time to relax. (If you lost those habits during nursing school, get them back!) Pick family outings or events and go spend time with the people who are important to you. People who are successful in what they do know how to take good care of themselves.

Article / Updated 09-21-2020

One of the best ways to prepare for the NCLEX-RN test is to answer as many questions as you can. The test has a language all its own; understanding the language will make you much more successful on the test. This article reviews 10 phrases most likely to appear in NCLEX-RN questions. When you understand these phrases, you'll be able to find the real question behind the question. As with many exams, answering NCLEX-RN questions correctly isn’t always as easy as it seems. Sometimes figuring out exactly what the question is asking can be difficult, which is why the first step is to find the keywords. Keeping an eye out for certain phrases that alert you to the keywords of a question can help you identify how to answer it successfully. These phrases usually relate to one of the five steps of the nursing process. Assessment and priority The first stage of the nursing process is always assessment. Common questions related to the assessment phase of the nursing process may require you to set priorities when performing patient assessments. Questions may ask which assessment is most important, has the highest priority, or is the priority for a particular client. These kinds of questions are likely to start with or include the phrases Which priority assessment or Who would the RN see first. The latter is a priority assessment of which client is in the most life-threatening condition. Practice question A nurse is caring for a client who has just had elective nasal surgery for a deviated septum. Immediately after the surgery, the nurse performs which priority assessment? (1) Measuring intake and output (2) Determining the client’s pain level (3) Checking for impaired swallowing (4) Assessing respiratory status The correct answer is Choice (4). The biggest keywords here are nasal surgery, highest priority, and immediately after surgery. When answering questions about priority assessments, remember that more than one answer option may be correct. In this question, all the options are assessments that should be performed immediately post-op nasal surgery. But the question asks which assessment assumes the highest priority, and for priorities you need to remember that life-threatening issues are the priority in every case. As a result of the nasal packing and edema of the airway, the nurse should carefully assess for signs of respiratory compromise. Nasal packing may also dislodge, resulting in obstruction of the airway. Diagnosis Questions relating to the nursing diagnosis step of the nursing process usually present information about a patient situation and ask you to identify an appropriate nursing diagnosis or the priority diagnosis. In order to make any kind of diagnosis, you need to Organize the data that you’re given Analyze the data Determine what you feel is the highest priority in terms of nursing care These kinds of questions are likely to ask Which nursing diagnosis is the most appropriate? Practice question A client with a newly created colostomy has verbalized to the nurse that he thinks the opening in his abdomen is disgusting and he doesn’t want to look at it. Which nursing diagnosis would be most appropriate? (1) Knowledge deficit related to the care of a stoma (2) Disturbed personal identity related to change in appearance (3) Disturbed body image related to colon surgery (4) Hopelessness related to irreversible changes in body functioning The correct answer is Choice (3). Organize the data (new colostomy, client’s feelings about the stoma, refusal to look at it) in the keywords. Then analyze that information and determine what the priority concern is. In this case, the primary concern is that the patient has verbalized negative feelings about his stoma in terms of how it looks. Therefore, the priority nursing diagnosis is disturbed body image. The client’s feelings aren’t related to a knowledge deficit but rather to a permanent change in physical appearance. Hopelessness may be an issue, but the question contains no data to support this diagnosis. Disturbed personal identity relates to a client’s inability to distinguish between self and nonself. Planning and assigning care Many exam questions address your ability to plan patient care that meets all the patient’s needs. Common questions pertaining to the planning step of the nursing process may address one of the following topics: Planning for delegation of tasks Developing patient teaching plans Formulating patient outcomes/goals Questions on planning for delegation of tasks may include phrases such as The nurse is assigning care, The patient understands teaching by, or A goal for this patient is. Practice question A nurse is assigning the care of a patient with a modified radical mastectomy to a nursing assistant. Which intervention can’t be delegated to the nursing assistant? (1) Collecting a clean catch urine specimen and sending it to the lab (2) Emptying the patient’s Foley catheter and recording output (3) Assisting the patient out of bed and into the chair on the first day post-op (4) Assessing the operative site for drainage The correct answer is Choice (4). When answering questions about delegating care, first look at who the care is being delegated to and consider what that person is qualified to do. The Nurse Practice Act and individual hospital policy define and limit the scope of nursing practice, but generally, unlicensed personnel aren’t permitted to perform patient assessments, administer medications, or perform medical treatments. Unlicensed personnel, such as nursing assistants, can perform activities such as ambulation, positioning of patients, bathing, hygiene measures, and collection of some urine and stool specimens. In this question, assessment of the operative site for drainage is a nursing responsibility and therefore can’t be delegated. The other activities can safely be performed by the nursing assistant, but the nurse is accountable for the assistant’s activities. The teaching plan Nurses are teachers; making sure that patients understand their care is an important part of nursing. Questions pertaining to patient teaching may be worded something like Which instructions would the nurse include in the teaching plan? Practice question The nurse is preparing for the discharge of a toddler admitted with nephrotic syndrome. Which instructions would the nurse include in the teaching plan for the parents? (1) “Call the physician if the child has an increase in urine output.” (2) “Keep the child away from others with infections.” (3) “Administer antipyretic medication as ordered.” (4) “Assess urine specific gravity every day.” The correct answer is Choice (2). Find who the client is, the condition, and what the question is wanting, in this case teaching plans. When answering questions about teaching plans, think about what you know about the patient’s condition and incorporate this information into the teaching plan. The child recovering from nephrotic syndrome should be protected from infection. The physician should be notified if the child has a decrease, not an increase, in urine output. Specific gravity assessments aren’t appropriate for a child being discharged to home, and antipyretic medication isn’t indicated. Outcomes and goals As a nurse, you need to know why you perform specific nursing interventions. In other words, what are you expecting to happen when you do certain things? These expectations are called expected outcomes and goals. NCLEX-RN questions on planning patient outcomes and formulating goals may contain the phrase Which would be an expected outcome. An easy way to understand this concept is to think about the expected outcome of taking, say, cold medication. If you take one of those fizzy tablets, for example, you probably expect not to have a cold anymore, or be able to breath freely. Practice question The nurse is planning care for a patient admitted with bacterial pneumonia. Which would be an appropriate expected outcome for the patient? (1) The patient performs activities of daily living without dyspnea. (2) The patient expectorates a moderate amount of yellow sputum. (3) The patient’s white blood count (WBC) is 14,000 cells/mm3. (4) The patient’s urine output is greater than 30 ml/hr. The correct answer is Choice (1). When formulating outcomes, first consider the patient and his or her condition. Figure out what the nursing or medical diagnosis is, and then ask yourself, “How will I know the patient is getting better?” An appropriate expected outcome Is observable and measurable Specifically addresses the patient’s nursing or medical diagnosis In this question, it’s evident that a patient with bacterial pneumonia is getting better when he or she can ambulate and perform activities of daily living without being short of breath. This activity is an observable, measurable goal that specifically addresses the patient’s condition. Expectorating a moderate amount of yellow sputum indicates that the disease process isn’t resolving. A white blood count of 14,000 is elevated (normal is 4,500 to 11,000 cells/mm3) and indicates an infection. Although a urine output of greater than 30 ml/hr is within normal limits, it doesn’t specifically address the patient’s pneumonia. Best response The implementation step of the nursing process refers to how the nurse carries out nursing actions. Common questions pertaining to the implementation step of the nursing process may ask you to Identify the nurse’s best or most therapeutic response in a certain situation Identify the nurse’s immediate or priority action Identify the appropriate nursing interventions for a specific disease or condition Implementation questions may employ the phrase Which would be the nurse’s best response? Practice question A client who has been hospitalized frequently for major depression tells the nurse, “I don’t understand why I get so depressed.” Which would be the nurse’s best response? (1) “I’m sure you’ll improve with the right medication.” (2) “Would you like to talk about the reasons you’re depressed?” (3) “This must be very upsetting to you.” (4) “Your depression is most likely caused by a chemical brain imbalance.” The correct answer is Choice (4). In answering implementation questions, carefully consider all the responses to determine which one contains accurate information and is therapeutic for the client. In this situation, the best response acknowledges that depression has a biochemical basis. Stating that the client will improve with medication or is upset doesn’t address the client’s immediate concern about the cause of his depression. Talking about the reasons for the depression isn’t the best response because it does nothing for the client other than increase depression. This situation is where you want the client to talk about his feelings or emotions. When you see this type of question, use therapeutic communication techniques such as Reflecting: Directing the client’s question back to client Restating: Repeating what the client has said Using silence: Allowing time for formulating thoughts Focusing: Keeping the conversation focused toward the task Nontherapeutic communication techniques include Asking closed ended questions: These questions elicit only a yes or no response. Giving advice: “You really shouldn’t . . .” Minimizing the client’s feelings: “Cheer up.” Making a value judgment: “I don’t think that’s good.” Priority action Nursing care actions need to be performed in a certain order. Some actions are always more essential than others, and you need to know what to do first. Exam questions relating to priority action are likely to be worded “What should the nurse’s priority action be?” or use the phrases initial action or immediate action. Practice question A client with chronic immune thrombocytopenic purpura undergoes a splenectomy. Upon receiving the patient in the PACU (postanesthesia care unit), the nurse immediately assesses the client’s airway and vital signs. What should the nurse’s next priority action be? (1) Checking the patient’s Foley catheter for urinary output (2) Administering pain medication as ordered (3) Checking the patient’s dressing for excessive bleeding and drainage (4) Administering platelets as ordered The correct answer is Choice (3). To determine priority action, first consider the patient and his or her conditions. Next, determine what the essential nursing interventions are for the condition and determine which condition is the most life threatening for the client. In this case, chronic immune thrombocytopenic purpura (ITP) is an immune-mediated disorder of platelet destruction. A client undergoing a splenectomy with a history of ITP is at high risk for hemorrhage, and therefore the priority assessment is to check the dressing for signs of bleeding. Although the nurse should check the urine output and pain level, these conditions aren’t immediately life threatening. Interventions Nursing requires you to anticipate what may happen with your patient given his disease process. Thinking ahead in this manner allows you to watch for signs of problems and intervene as quickly as possible. To determine whether you know the appropriate nursing interventions for a particular disease or condition, exam questions on this topic usually ask “The nurse can anticipate which intervention?” Practice question A client has developed hepatic encephalopathy as a result of liver disease. Which intervention can the nurse anticipate incorporating into the plan of care? (1) Restricting fluid to 1,000 ml/day (2) Inserting a nasogastric tube (3) Administering intravenous salt poor albumin (4) Implementing a low-protein diet The correct answer is Choice (4). From the way the question is worded, you know that only one of the interventions listed is a priority in this situation. When hepatic encephalopathy develops as a result of liver disease, one of the treatment goals is to reduce the production of ammonia. One of the by-products of protein breakdown is ammonia, so protein should be limited in the patient’s diet. Fluid restriction and salt poor albumin are used to treat ascites (a complication of liver failure). A nasogastric tube may be inserted as the disease progresses, but it isn’t the best answer here. Further teaching The last step of the nursing process is evaluation. Common phrases in these types of questions pertain to determining whether patient goals have been achieved and interventions have been successful. For example, questions may include the phrases Further teaching is necessary when, Interventions have been effective when, or Intervene when. Practice question The nurse is caring for a client receiving subcutaneous injections of enoxaparin sodium (Lovenox) for a pulmonary embolism. Which statement made by the patient indicates that further teaching about the medication is needed? (1) “I’ll watch for signs of bleeding and notify my physician immediately if I notice anything.” (2) “I’ll avoid medication that contains aspirin.” (3) “My doctor will be checking my platelet count regularly.” (4) “I’ll need to have my coagulation levels checked daily.” The correct answer is Choice (4). Needs more teaching means you’re looking for the incorrect statement. When you see this type of question, rephrasing the question in your mind is often helpful to figure out what it’s really asking. In this case, you can rephrase the question to be “Which is an incorrect statement made by the patient?” Choice (4) is incorrect and is therefore the right choice. Enoxaparin sodium (Lovenox) is a low molecular weight heparin used to prevent deep vein thrombosis; it’s also given to patients with pulmonary edema. As for the other options, patients with normal coagulation who are receiving enoxaparin don’t require regular monitoring of coagulation levels. The patient needs to watch for signs of bleeding and to avoid aspirin. Platelet levels are checked periodically because thrombocytopenia is a potential side effect of the drug.